Once you have read this blog
post gets its context and then you can read this either as a commentary of the
WSJ article as relevant to NHS or on its own. This blog is deliberately off-key,
the topic is such, bear with me. Compared to many healthcare systems we do quite
well in the NHS. Could we do better? Of course yes but how we do that will
define our future.

We are the management and we will tell you how to end management!?!?!

At a broader
level, in the NHS there are no examples that I can think of where corporate
structure or management has been ‘ended’. The previous government did good work with top down waiting
times and so on; the present government is attempting top down radical change
in organisational structures. The government is trying to get us do differently. When individuals try to do something
creative, the organisations and the NHS as a whole tries to look at 'where and
how it fits in with the overall plan'. But in the
public sector there is the government not just wanting us to do different but
also telling us how precisely to do it; with organisations 'encouraging
innovation and creativity' only if it fits in with pre-defined policies. But that is what
modern business is trying not to do; modern thinking in management is
not telling people what to do but to let people to do things first and
the management to amplify the good ideas.

Thinking of me vs thinking of you

At the
narrower level, trainees (I am talking about all trainees in the clinical
areas- not just doctors) are taught to think of how they are learning and
improving themselves; never to explicitly think about their contribution to the
organisation. In fact, often people think that their contribution to healthcare
as such starts only when they stop becoming trainees. By that time the mind set
becomes so fixed in thinking inwardly about the self and not outwardly about
others that it becomes very difficult for the rest of their lives. Careerism
becomes the mantra for many people in healthcare; we always thought this was
the case in the private sector - true but that trend is changing in some areas.

Best with limits

This leads
to people taking very defensive attitudes. Most people in healthcare management
are either numerically shy or numerically illiterate. They are unwilling to
make a personal numerical prediction on their or their
department/division/directorate’s improvement based on a measurable internal
parameter due to the fear that they may be unable to stand by it. In any case
most of the numbers are geared towards predefined reporting parameters. People
who work in the NHS also seem to think that they are somehow very altruistic
and have a high sense of entitlement. That attitude is even more profound in
the clinicians with clinicians tending to believe that they express their
altruism by their very individualistic approaches to healthcare. It is also
possible that there are certain kind of people who are drawn to public services
(possibly risk averse, change shy, rule-bound, authority loving, service minded
and so on) and it would be difficult to use the same methods as for instance in
Google to achieve a new management approach.

At both the
above levels, healthcare and NHS is thought to be too important and too costly
to be creative or innovative; the phrase used is 'risk'. Healthcare especially
in Europe and even more so in UK has innumerable external controllers and
bodies telling people what to do and how to do it that it simply chokes off
creativity even before it begins. In other industries there is an obligation to
do some degree of statutory reporting with no real controls on how they do
their business.

So, it seems
like what the above WSJ article is saying is not possible in UK healthcare at
all. There seems no space that is available or can be created for those
concepts to happen without falling foul of something or someone. But there lies
the opportunity as well to ‘end management’ and create self-sustaining systems.

Blue skies

Hence, I can
now boldly enter the imaginary world to explore how the 'wisdom of the crowds'
can be harnessed. I think the way to do it is to disengage from current
conventions and demonstrate its success. That does not mean rebelling,
non-cooperating, behaving illegally, not concentrating, becoming disenchanted
or any such thing. It is using our own methods to satisfy our requirements and
our clients’ requirement rather than using a method or doing a thing to satisfy
an external definition.

For instance
when the roads around Birmingham were choking instead of building a new road,
they opened the hard shoulder to traffic which in other roads is actually
illegal; peak time traffic situation has improved since in that area. Compare
that with an example of the situation in some hospitals where they buy yet
another business intelligence interface/data-mining tool to provide information
at service line specialty level when the managers and clinicians often feel
that human connectivity was the issue that needed resolving to enable their
older software to be used effectively. Often the tool is not really the problem,
our thinking is.

Let us
assume for example that one of our services is not accredited by some specialty
society because we did not meet one or more of their requirements in the way
they wanted. Normally the tendency would be either to stop that service or to
work very hard to meet that accreditation standard. However, if our results in
that particular specialty or aspect is better than anywhere else, would we as
an organisation, anyone in the specialty society or the general society as a
whole be unhappy? Certainly not. In this scenario the badge of not being
accredited becomes a badge of honour. The problem is we do not think like that
in the NHS. We probably should.

Like the
Birmingham roads, what 'illegal' things could we do to make ourselves better?

Obviously we
should disengage and develop only if it is beneficial to our hospital and
patients and we are able to track it and prove it contemporaneously.

Is this an example of wisdom of the crowds in the real world of
healthcare?

Finally let
me try a hypothetical yet hopefully practical proposition to disengage and
demonstrate. There is a focus on Unplanned emergency re-admissions and we may
not get paid for such re-admissions. I am aware of some of the things that we
have started doing to tackle this issue. Let me put to you a potentially
disruptive solution in the 'end of management' mode

a) not offering routine follow-ups for any patient who is discharged from the ward (medical, surgical,
post-operative)

and instead

b) Guaranteeing
a clinic slot within a defined time (48 hours to one week as agreed) should the
patient choose to contact us.

My
hypothesis is, this approach will reduce unplanned emergency readmissions as
the issue is often/mostly to with patient concerns on access (rather than real
life-threatening matters); the 'routine' follow up itself is mostly to satisfy
clinicians habit rather than a scientific finding that all complications in all
patients happens precisely 3 months after seeing the doctor and hence patients
need a 3 months appointment. This will also clear up the 'congestion' we have
in our clinics.

Okay, where
is the 'wisdom of the crowd' here? The crowd in our example is the patient; and
the wisdom is the patients’ knowledge about their own health on what is wrong
with them and they should be able to access us when they find something wrong
with them. This is of course one step further than the current thinking on
'crowd' which is usually the employees in a large organisation. We even need to
change the definition of crowd to suit our requirement.

Rambling ambiguity and the threads of new systems

We can
predict that the conventional management methods will not work in the 21st
century. End of management as we know it is not chaos as many would like us to
believe. New models are not apparent or clear yet. Perhaps there may not be one
new model; possibly there may not be a well defined model at all. There are emerging
themes; democratisation of data, data mining, crowd sourcing, coping with anti-knowledge,
cloud care and dumb-terminals, many more............ It is not these themes
that are important; it is how we implement these themes that are relevant. We
can be told how to do it thus not ‘ending management’ or we can show how we do
it.

Thank you
for getting to this sentence of the blog. If you thought this was rambling
ambiguity, I am grateful for your attention and will do better next time. If
there are some threads that we can build on then I have achieved my aim.

1 comment:

You are absolutely on the spot; we are forming a healthcare reform community with startlingly similar beliefs and would like to keep sharing views/comments - please visit: http://www.optimishealth.co.uk/default.html